The Intensive Care Units (ICUs) we know about are filled with the rhythmic hum of ventilators, keeping patients alive in a seemingly serene state, but reality often masks the horrors of their condition. Since the 1980s, the practice of ventilating patients has evolved, but unfortunately, the approach to sedation has remained stagnant. Today, deeply sedating patients into medically induced comas upon ventilator connection is standard practice, justified under the guise of humane care. However, the myths surrounding this practice conceal a far more alarming truth - a truth that critical care nurse practitioner Kali Dayton, DNP, AGACNP, seeks to expose.
There are various myths about sedation. These include the belief that patients are 'sleeping', which is not true. The sedation disrupts brain activity and can lead to confusion and hallucinations, known as delirium. Many ICU clinicians believe that patients are peacefully unaware of their surroundings while comatose under sedation. However, many patients may still be aware of their surroundings but lost in a world of delusions resulting in a greater risk of post-ICU PTSD. Ironically, these myths that medically-induced comas are harmless, humane, and essential for all patients on mechanical ventilation, contradict the evidence that demonstrates that sedation increases the likelihood of mortality, complications, and prolonged ICU stays. Most ICU patients can and should be awake and moving while on the ventilator, despite some exceptional cases that require continuous sedation.
Furthermore, healthcare inequality in critical care makes it even more difficult and even more unfavorable for patients. Issues like socioeconomic disparities and their lack of healthcare access play a part in outcomes for Hispanic patients with outdated sedation practices in the ICU, causing greater disparities for them.
Medically induced comas may be essential for some ventilated patients, but that should not be the default approach. Research supports the safety and feasibility of mobilizing ventilated patients, with early mobility programs yielding significant benefits. Kali Dayton, a critical care nurse practitioner, and CEO of Dayton ICU Consulting, states, "Automatic deep sedation for every patient on a ventilator is often more of a cultural practice than a medical necessity, and for most patients, may not be worth the high risks. In order to improve outcomes, it is important to avoid sedation and mobilize patients in the ICU whenever possible. The less delirium and atrophy patients endure, the more likely they are to survive and the quicker they will be able to recover from critical illness and return home."
The practitioner further emphasizes the importance of addressing the financial repercussions of being in the ICU. Sedation can cause brain injuries in patients, making mobilization difficult and increasing their reliance on the hospital. They frequently require ongoing care because of cognitive and physical impairments. In the United States, nursing homes and rehabilitation facilities are overcrowded, especially after the COVID-19 pandemic hit, resulting in higher healthcare costs.
These patients are not rehabilitated, and they end up developing infections like pneumonia, foley infections, central line infections, and pressure injuries. Furthermore, hospitals are financially liable for these iatrogenic complications. Kali contends, "Failing to practice early mobility in the ICU is failing to prevent hospital-acquired brain dysfunction (delirium) and hospital-acquired weakness. This leads to an incredible devastation for hospitals, staff, and most of all, patients and their families."
Beyond the human toll, outdated sedation and immobility practices are a heavy financial burden. According to studies, delirium increases healthcare costs by 40%, while ICU-acquired weakness (ICUAW) leads to a 30.5% rise in expenses. These complications have increased mortality, prolonged hospital stays, increased readmission rates, and strained healthcare resources. Kali Dayton encourages and promotes the 'Awake and Walking ICUs' approach. This revolutionary approach encourages patient mobility after intubation and promotes minimizing sedation, which will significantly improve outcomes.
ABCDEF bundle, a readily available toolkit also helps guide clinicians on how to use evidence-based sedation and mobility practices. This toolkit assists in the prevention and treatment of these conditions, with studies indicating that even a lower level of compliance can reduce healthcare costs by 30%. Another study on this approach found that a 300% increase in early mobility can decrease hospital-acquired infections by 60%. This just shows and proves that the more the patient is awake and mobile, the more all of these outcomes improve. These practices have also been proven to enhance successful extubation, discharges from ICU and home, survival chances, functional independence, and quality of life.
Kali Dayton advocates for an increase in support for ICU teams to provide this level of care. This support includes safe staffing ratios, training, mobility technicians, and safe patient-handling equipment. ICU clinicians will enjoy the improvement in the workplace environment and find greater fulfillment in their careers as they witness their patients being successfully liberated from the ventilator and walking out of the ICU doors. Hospital administrators are wise to ensure that their teams are able to adopt an Awake and Walking ICU approach as the return on investment is significant. Investing thousands of dollars can result in millions saved.
Embracing the principles of the 'Awake and Walking ICU' and partnering with leaders like Kali Dayton, healthcare institutions can usher in a new era of compassionate care, improved patient outcomes, and decreased healthcare costs.
